Virginia's Next Steps to Improve Health Care Value - Beth A. Bortz, President and CEO - VBID Health
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Virginia’s Next Steps to Improve Health Care Value
Beth A. Bortz, President and CEO
VCHI Board and Leadership Council AARP Virginia GlaxoSmithKline Sentara Advocate Health HCA Virginia UnitedHealthcare Aetna Inova Health System UVA Health Care System Anthem Johnson & Johnson Va Academy of Family Physicians APC LabCorp Va Association of Health Plans Augusta Health Maxim Healthcare Services VCU Health Aviant Health MSV Foundation Virginia Health Care Foundation Ballad Health Merck Va Hospital and Healthcare Assn Biogen Novo Nordisk Va Oral Health Coalition Boehringer-Ingelheim Optima Va Community Healthcare Association Bon Secours Virginia PATH Foundation Va Council of Nurse Practitioners Carilion Patient First Virginia Nurses Association Cigna Pfizer Virginia Premier Cogit Analytics PhRMA Walgreens Commonwealth of Va Privia Health Westrock Dominion Energy Riverside Health System Workplan GIST Healthcare Sanofi
Our Strategy 1. Identify: Build consensus around the Choosing Wisely® principles and the need to measure low value care 2. Measure: Leverage data from Virginia’s All Payer Claims Database and apply the Milliman MedInsight Health Waste Calculator with the aim of prioritizing which medical tests and procedures should be reduced. 3. Report: Share early data with partners to test validity and acceptance. Build consensus around initial focus and develop an action plan. 4. Reduce: Test multiple improvement strategies.
Our Most Recent Data
January 2019
Reporting Period 2017
Number of Measures 42
CMS Data Included? Yes
Dollars Spent on Unnecessary Services $747 million per year
Unnecessary Services Identified 2.07 million per year
Virginia Overall Results – 2017 Summary
39% of members exposed 35% of services measured
to 1+ low service were low value
$11.48 PMPM in claims were
unnecessary
Top 5 Measures by Percent of Low Value
Dollars for Virginia - 2017
MEASURE RISK OF % of Low Average Proxy Cost Low Value
HARM Value Per Service Index
Dollars
Don’t obtain baseline laboratory studies in L 29% 478 82%
patients without significant systemic disease
undergoing low-risk surgery.
Don’t routinely order imaging tests for L 23% 386 54%
patients without symptoms or signs of
significant eye disease.
Don’t place peripherally inserted central H 8% 18,154 77%
catheters (PICC) in stage III-V CKD patients
without consulting nephrology
Don’t order annual electrocardiograms M 7% 329 8%
(EKGs) or any other cardiac screening for
low-risk patients without symptoms.
Don’t do imaging for low back pain within L 4% 1,673 67%
the first six weeks, unless red flags are present
We Have 4 Years of HWC Data…What’s Next?
1. Incorporating it into a bigger “value” picture – the
Virginia Health Value Dashboard
v 2018 and 2019 dashboards are now complete
v 5 additional HWC measures in March 2019 – utilizing Version 7
v Partnership with Catalyst for Payment Reform provided
Scorecard 2.0 data (2 dashboard measures)
v Partnership with Altarum to conduct a Consumer Healthcare
Experiences State Survey (CHESS) will garner more data (could
result in future dashboard measures)
2. Using the Dashboard as a focus to take action
2019 Dashboard (2017 Data) Low Value Care Measures
2019 Dashboard (2017 Data) High Value Care Measures
Using the Dashboard to Focus Action • FQHC Collaborative • Arnold Ventures Grant • Merck Grant
FQHC Collaborative
In 2018, 18 Virginia FQHCs participated in a pilot where each received
site-specific dashboard results, as well as a combined performance
report. From the combined report, we see that:
v FQHCs outperformed or were equal to other statewide providers on
the provision of the 5 HWC measures.
v For the measure “to not obtain baseline laboratory studies for
patients without significant systemic disease undergoing low-risk
surgery” the FQHC rate was 18% lower than the state rate. This
represents $336,000 in avoided costs.
v These results are not risk-adjusted. Given the population served by
Virginia’s FQHCs, risk-adjustment will likely improve the FQHC
performance.
v FQHCs do have areas where their non-risk adjusted performance is
below statewide rates – particularly in diabetes care and potentially
avoidable ED visits and avoidable hospital admissions. They will
target their improvement initiatives accordingly.
The FQHCS, through their association, plan to expand this pilot in 2019
and have shared their initial results with HRSA.Exciting New Partnership • Yesterday at the VBID Summit, Virginia HHR Secretary Daniel Carey, MD announced that VCHI was awarded a $2.2 M grant to launch a statewide pilot to reduce the provision of low-value health care. • The initiative will span 3 years, with an additional 6 months for evaluation. • It will employ a two-part strategy to reduce 7 sources of provider-driven low value care and prioritize a next set of consumer-driven measures for phase two. v Part One – Health System Learning Community v Part Two – Employer Task Force on Low-Value Care
Health System Learning Collaborative: Project Partners
• The Health System Learning Collaborative will include 6 Virginia
health systems and 3 clinically integrated networks. They are:
v Ballad Health
v Carilion Clinic
v HCA and Virginia Care Partners
v Inova and Signature Partners
v Sentara and Sentara Quality Care Network
v Virginia Commonwealth University Health System
• Together these partners represent 900+ practice sites and cover 4 of
Virginia’s 5 geographic regions.
• Sites include hospitals, ambulatory care centers, ancillary centers,
and primary, specialty, and surgical care centers.Health System Learning Collaborative: Description
• The health systems will begin by targeting the #1 source of low-
value care in Virginia – unnecessary diagnostic and imaging
services for low-risk patients before low-risk surgery. Known as
“Drop the Pre-Op” this comprises 3 different tests and procedures.
• Once “Drop the Pre-Op” is underway, they will tackle 4 other
provider-driven tests and procedures:
– Cardiac testing (2) (both EKGs and cardiac stress tests for low risk patients
without symptoms);
– Imaging for patients without symptoms or signs of eye disease; and
– Peripherally-inserted catheters in stage III-IV chronic kidney disease patients
without a nephrology consult
• The health systems will be randomly assigned to one of 3 cohorts
and the active intervention period for each cohort is 18 months.Health System Learning Collaborative: Description
• Each health system will establish a clinical leadership team (CLT).
• CLTs will be provided with a rich set of resources to support their
delivery system change. Resources include:
– Access to national experts through a six-part CME-approved speaker series
and expert faculty office hours
– Access via an interactive private online community to the latest research,
toolkits, and Choosing Wisely educational materials (innovatevirginia.org)
– Performance reports from the Milliman MedInsight Health Waste Calculator
depicting individual clinicians’ performance on the 7 selected measures and
coaching on how best to maximize the impact of the performance reports.
• The CLTs will also participate in monthly conference calls with their
cohort partners and the Project Leadership Team to share
emerging knowledge and best practices.Employer Task Force: Description
• The Employer Task Force will include 15-25 employers, selected in
partnership with the Governor’s office, the Virginia Chamber of
Commerce, and the Virginia Business Council.
• The purpose is to increase employer knowledge concerning the
challenge of low-value health care, expose Virginia employers to
employers that are mobilizing for change, and engage them in specific
actions they can take in employee communications, benefit design, and
contracting to drive improvement.
• The task force will:
– Prioritize up to 6 consumer-driven low value care measures for improvement;
– Develop an action plan to reduce consumer and provider-driven low-value
services; and
– Conclude with a combined conference with the health system CLTs. At this
conference, A Virginia Plan to Improve Health Value will be developed.Project Aims
• In three years, we will produce a 25% relative reduction in seven
low-value care measures that are provider-driven while prioritizing
up to six consumer-driven measures for our next phase of work.
• Additionally, we will:
vincrease clinician competence in reviewing performance reports and
implementing targeted interventions to improve outcomes;
vimprove understanding of which interventions are effective in reducing
seven provider-driven low value care tests and procedures and provide
health systems and practice leaders throughout the country with tested best
practices they can implement;
vreduce the physical, emotional, and financial harm patients experience
from unnecessary tests and procedures;
veducate Virginia employers (including state government) on the actions
they can take to drive complementary payment reform that better
incentivizes value in health care.Project Leadership Team • We could not undertake a project of this magnitude without a strong project leadership team. Our team includes: v VCHI staff, Board of Directors, and Advisory Leadership Council v Virginia state government and Secretary of HHR, Daniel Carey, MD v Virginia’s health systems and the Virginia Hospital and Healthcare Association v Virginia Health Information (APCD) v Milliman MedInsight (Health Waste Calculator) v Virginia Chamber of Commerce and the Virginia Business Council v John Mafi, MD (Lead Evaluator) and Steve Horan, PhD (Survey Design/Evaluation Support) v Howard Beckman, MD; Michael Chernew, PhD; A. Mark Fendrick, MD; Catherine Sarkisian, MD, MSHS; Lauren Vela, MBA; and Daniel Wolfson (Project Faculty)
And to Address the High Value Side… • VCHI has also been awarded a $225K one year grant from Merck for its “Virginia Vaccinates: Improving the Commonwealth’s HPV Coverage” initiative. • The initiative will create an HPV learning collaborative comprised of 40 pediatric and family practice sites, representing 320 physicians, nurse practitioners, and physician assistants. • This sites will represent the West/Southwestern regions of Virginia and will include practices from three health systems: v Ballad Health, v Carilion Clinic, and v UVA Health System
And to Address the High Value Side… • All participating practices will: v Send designated clinicians to a half day regional kickoff session; v Designate time to work twice monthly for six months with a virtual practice coach; v Participate in monthly HPV educational webinars; v Engage in an online HPV learning collaborative community; and v Review practice performance reports and implement practice improvements.
Moving Forward VCHI will continue to: • Update and report on Dashboard results; • Add and subtract Dashboard measures, as resources and data warrant; • Focus action around Dashboard identified opportunities; • Build statewide and regional collaboratives to maximize impact; • Evaluate project implementations and share best practices for future replication
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